Attitudes towards the neurological examination in an unwell neonate: a mixed methods approach

Background The neurological examination of an unwell neonate can aid management, such as deciding if hypothermia treatment is warranted in hypoxic ischaemic encephalopathy or directing investigations in hypotonic neonates. Current standardised examinations are not designed for unwell or ventilated neonates, and it is unclear how confident paediatricians feel about the examination or what aspects they perform. Aim This study aimed to review the confidence of UK paediatricians on the neurological examination in unwell neonates, describe their attitudes towards it, and determine what could improve practice. Methods An explanatory sequential mixed methods approach (QUAN → QUAL) with equal weighting between stages. A survey on attitudes to the neonatal neurological examination was sent to all UK neonatal units and members of the British Paediatric Neurology Association. Volunteers were sought for semi-structured interviews. Thematic analysis was used to interpret qualitative data, which was triangulated with quantitative questionnaire data. Results One hundred ninety-three surveys were returned, 31.0% from neonatologists, 9.3% paediatric neurologist. The median range for confidence was 4 (IQR3-5). Twenty-three interviews occurred. Thematic analysis revealed three themes: “Current culture on neonatal units”, “ Practicalities of the neurological examination in unwell neonates”, and “Changing the culture”. Most interviewees did not feel confident performing or interpreting the neurological examination in unwell neonates. Many units had a culture of seeing it as low priority, did not see its relevance in the acute management of unwell neonates. A few interviewees worked in units with a positive culture towards the neurological examination who used adapted standardised examinations and provided training. 72% of questionnaire responders wanted a new standardised neurological examination designed for the unwell neonate, which should be short, utilise pictures like the Hammersmith Neonatal Neurological Examination, contain an assessment of consciousness, be developmentally appropriate and achievable in unwell, ventilated neonates, be accompanied by a schematic to aid interpretation, and for greater training and assessments of competence. Conclusions There are barriers preventing paediatricians being able to perform a neurological examination in unwell neonates, and a culture of neurophobia is common. A new standardised examination is needed, alongside aids to interpretation, training, and assessment. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03616-4.


Opening question
Can you tell me about your experiences of examining a baby neurologically?
• What sort of conditions may these babies have?
• How do you feel about examining a sick baby neurologically? Why?

Questions on attitudes to the neurological examination
Are there any situations where you think you should have done a neurological examination of a neonate but didn't?
• If yes, what stopped you from examining the baby?
• How often does that happen? I'm interested to hear your thoughts on your colleagues' / trainees' practice -do they examine all of the babies they should neurologically?
• If babies are always examined when they should be, refer to survey data: o We did a survey of UK paediatricians and it suggested 1/5 of unwell babies didn't get a neurological examination when they should have -why do you think this happens?
Generally speaking, how well do you think trainees / your peers examine babies neurologically?
• Sometimes important decisions are made based on a trainees' examination -such as whether a baby with HIE should be transferred for cooling or to choose investigations in a floppy baby. How much should we rely on this assessment to make decisions? Why?
If the baby is ventilated, cardiovascularly unstable, or with umbilical or arterial lines, does this affect the examination? How?
• Do you think there are any solutions to these problems with examining a baby who has lots of tubes, leads and venous lines in place? Some people have told us that medications like sedation and paralysis affect whether they do a neurological examination. Do you think it is worth doing an examination whilst the baby is sedated? If not, when is the time that the first neurological examination should be performed? Does it always get done at that time?

Things to do before the start of the interview:
• Introduce yourself and explain you are a paediatric clinical research fellow. You are learning more about how doctors feel when they examine a sick neonate neurologically, and how well they think they can interpret the results of the examination • Ensure you are somewhere quiet with minimal distractions • Check the interviewee is happy to continue with the project • Ensure they know you will record them on the dictaphones • Ask them to sign and initial (NOT X) the boxes on the consent form • Start both Dictaphones 2 Some paediatricians tell us the neurological examination is either not important or isn't prioritised over tasks like siting intravenous lines. Is this your experience?
• If it is not a priority, how often do you see people going back to do it at a later time?
• Our survey suggests that people perform a cardiovascular and respiratory examination but not the neurological examination. Is this your experience? Why do you think that happens?
• Some people say they find it best not to disturb the sick baby rather than do a neurological examination. What do you think about that statement? Is that your experience for the examination of other systems too?
• We have been told that some nurses caring for a sick neonate discourage doctors from performing examinations. Is that your experience? What are your thoughts on that?

Questions on specific aspects of the neurological examination
Please look at the list of parts of the neurological examination [figure one] • Which parts do you find the hardest to assess? Why?
• How well do you think people distinguish tone from power in a neonate?
I'd like to talk about how we assess a neonates' level of consciousness. How do you assess this?
• Do you think this method is reliable?
• How well can this method be used by different members of the team to assess if a baby's conscious level is improving or deteriorating over time?
• The Glasgow Coma score [ Figure two] is used in older children and adults. We have a sheet with the modified child GCS on. Have you ever used it in a neonate?
o What are your thoughts on using the GCS in neonates? How could it be improved?

Documentation of the neurological examination
Our survey of UK paediatricians suggested that there was no detailed, high quality documentation of a neurological examination in the medical notes in around 3/4 of unwell babies with neurological problems. Does that fit with your experience?
• Why do you think we found that result?
• Could it reflect problems with documenting the examination?
• How can the documentation of the neonatal neurological examination be improved? o Making sure everything was done that should be?
• How useful do you think it is to have the pictures on the proforma?
• Are there any parts of this examination that you think are really useful?
• Are there any parts of this examination that you think are not possible to do in sick neonates?
• Are there any parts of this examination that you think are not useful?

Interpretation of the neurological examination
I'd like to talk about how people interpret the findings of a neurological examination. For example, how well they tell if the baby is normal or not and decide if the cause of a baby's floppiness is because of a disorder affecting the brain, spine, nerves or muscles. What is your experience?
• Why do you think people find the interpretation of the neurological examination difficult?
• What can be done to make it easier to interpret the results and make lists of differential diagnoses?
Training I'm interested in how people learn to perform a neurological examination in a newborn baby -what type of training did you receive?
• Do you think that training was sufficient?
• Do you think this should be a training priority?
• What could be done to improve training?

Designing a new neurological examination
We are working on designing a neurological examination of the sick neonate.
• What are the important parts of the examination that we should include?
• How do we ensure it is documented well in the notes?
• Are there any ways we can help doctors interpret the results?
• How do we make it easy to monitor the changes in a neonate neurologically over time?
• Can you tell us if there are any ways we can improve confidence of doctors and nurses using the examination, particularly if they are not doing it regularly?
• How can time/length of examination best be managed?

Closing questions
• If we had to make sure there were one or two things we should put in a new neurological examination, what would they be?
• Are there any other things you would like to talk about that we haven't discussed?

Figure two: The Modified GCS For Children (BPNA 2001)
Pain should be made by pressing hard on the supra-orbital notch (beneath medial end of eyebrow) with your thumb, except for M4, which is tested by pressing hard on the flat nail surface with the barrel of a pencil.
Score the best response with unclear or asymmetrical. If in doubt repeat after 5 minutes.

Aspect to be examined Criteria Score
Eye opening Spontaneous 4 To voice 3 To